Provider Demographics
NPI:1194008698
Name:KERBY BEHAVIORAL DEVELOPMENT, PLLC
Entity Type:Organization
Organization Name:KERBY BEHAVIORAL DEVELOPMENT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KERBY
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:918-718-9004
Mailing Address - Street 1:PO BOX 613
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-0613
Mailing Address - Country:US
Mailing Address - Phone:918-718-9004
Mailing Address - Fax:918-431-1180
Practice Address - Street 1:402 JANET ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-7028
Practice Address - Country:US
Practice Address - Phone:918-718-9004
Practice Address - Fax:918-431-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK819101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty